SUMMARY:

• Confidential has more than 12 years of professional management consulting experience including 10 years in the Health Care and the Life Sciences industry.
• Confidential has worked with various organizations leading projects in the areas of strategic business development and program/project governance including new business/product development, process improvement, system implementation, monitoring and reporting.
• Confidential has proven success in working with cross - functional/internal business teams including PMO, IT, Finance, Executive Management, Compliance, Internal Audit, Delegation/Oversight and Operations Management teams.

AREAS OF EXPERTISE:

• Program / Project Management and Governance
• Business / Regulatory Requirements Mapping
• Enterprise Roadmap Development / Execution
• Strategic Analysis
• Data Integrity and Quality Controls
• Cross-functional Accountability Mapping
• Regulatory Compliance and Business Readiness
• Data Mapping / Validation
• Project Portfolio/IT Management Transformation
• Executed organization and information management change for single platform, enterprise-wide, proprietary system for multi-state health plan with multiple lines of business and subsidiaries
• Executed enterprise strategy to expand existing products/services into multiple states and become a new entrant into the commercial market under the healthcare exchange
• Prospective Provider Engagement Implementation (Provider Program Process Enhancement; Regional BCBS Health Plan)
• Expanded start-up (subsidiary) program to Michigan providers, doubling the size of the program in less than four months
• Developed enterprise playbook and execution strategy for multi-state expansions
• Financial Transformation
• Developed and executed enterprise strategy to align financial data reporting globally across 42 facilities
• Developed project/program governance model to manage teams across Asia, Europe, Australia, Africa, North and South America
• Confidential Sanctions Remediation
• Led a team that provided audit readiness support for a large national Confidential Part D plan facing intermediate sanctions.
• The team was successful in assisting the client in obtaining release from sanctions through rigorous planning and preparation across four elements including interview preparation, universe creation, operational readiness and sanctions validation attestation.
• Medicaid Health Plan Start-up
• Led a team to launch a new Medicaid health plan for joint venture between two large national health plan conglomerates. The team implemented new PBM operations for the Medicaid health plan from regulatory requirements gathering through state readiness.
• Multi-State Health Plan Accreditation Reporting Analysis
• Conducted analysis of more than 300 reports across five health plans and provided detailed data mapping and instruction guides to streamline reports across differing regulatory requirements in five states and three accreditation bodies. Identified roles and responsibilities across business units and identified enterprise centralization and control activities.

PROFESSIONAL EXPERIENCE:

Confidential, Detroit, MI

Manager, Management Consulting

Responsibilities:

• Developed project management templates for the Confidential including project charter, status report, project dashboard reports, etc.
• Project managed multiple projects to support Confidential during times of over capacity; Projects ranged in size from medium to large with varying degrees of complexity; Responsible for all aspects of project delivery including team management, charter, business requirements gathering, design and project close activities
• Engaged a project beginning in Phase III (in flight for two years) to deliver implementation of a Specialty Drug prior authorization and claims payment system involving a new third party vendor to Confidential

Confidential, Detroit, MI

Manager, Health Industries Advisory

Responsibilities:

• Responsible for leading and managing client facing teams in a wide variety of health care strategy and operations projects ranging from regulatory change requirements to new business/product development
• Develop customized approach and solutions specific to client needs while managing to strategic vision, risk management, regulatory requirements and business/product phase of life cycle needs
• Develop health care advisory tools, solutions and accelerators specific to health plan business strategy to create a competitive advantage over competing consulting firms
• Network with internal and external leaders/stakeholders to identify new opportunities in entrance markets
• Manage project sales and pursuit teams including SOW management, invoicing, project budget and resource request fulfillment

Confidential, Detroit, MI

Manager, Management Consulting

Responsibilities:

• Developed and implemented solutions to support Confidential objectives to increase overall value and quality of care to the member population
• Implemented project governance and program management strategies to create repeatable implementation processes including business/product design, IT and business requirements gathering, system and process development
• Developed and implemented tools to track, monitor, report and forecast program strategies for executive level consumption and portfolio management
• Conducted detailed analysis of data gathering/reporting processes and develop tools, processes and controls for integrity and consistency across operations and leadership teams
• Designed and developed implementation playbook/instructional guide for external consumption with potential implementation partners

Confidential, Detroit, MI

Manager/Health Plans Practice

Responsibilities:

• Organize and lead cross-functional project teams across entities with integration of risk management, regulatory compliance and oversight controls
• Conduct risk assessments including but not limited to CMS compliance, CMS audit protocols, internal audit process review, controls testing/review and develop detailed reports including corrective actions and future state objectives
• Develop and deliver customized project governance infrastructure and tools capable of supporting 50-100 person project teams including communication, program reporting, issue/risk management and strategic alignment
• Lead internal practice development initiatives to create proprietary tools, solutions and methodologies specific to government health plan processes and program delivery
• Lead internal practice development teams to develop new service offerings and tools for emerging health care initiatives specific to Affordable Care Act legislation and CMS activities
• Authored regulatory compliance publications and internal materials for new hires and junior staff specific to Confidential and Medicaid health plans
• Responsible for mentoring and counseling junior staff in, core consulting and health plans specific project/program management
• Responsible for sales and managed revenue and have documented success in managing “Green Dot” projects (internal and external) between Advisory and Consulting divisions

Confidential, Detroit, MI

Head of Department, Project Management

Responsibilities:

• Responsible for enterprise wide coordination of operations and administrative projects for three subsidiary companies including two Medicaid health plans, one Confidential D-SNP as well as the PBM.
• Responsible for coordination of internal process improvement and change control processes for proprietary software as well as administrative and operational processes.
• Responsible for reporting to CEO, COO, CIO and CMO for overall progress of development and implementation projects.
• Served as the champion for research, development and implementation of programs to support managed care businesses.
• Responsible for the design, development and implementation of enterprise wide documentation,, change management processes and corporate style guides & templates.
• Responsible for coordination of corporate compliance initiatives for quality accreditation and government contracts including material submission as well as onsite visits, requests for proposal, auditing and monitoring programs.
• Designed and implemented complex project management process for identifying critical business needs and the appropriate front end data analysis to support long range project goals and performance metrics
• Designed, developed and implemented corporate standards for process change control & management, proprietary software versioning, policies, procedures and for all core business processes

Confidential, Southfield, MI

Consultant, Corporate Administration

Responsibilities:

• Responsible for reporting compliance readiness and project status to COO and the Vice President of Corporate Administration for all compliance activities and day to day operations of state and federal contract requirements.
• Responsible for compliance oversight during Confidential ’s acquisition of University of Michigan’s health plan and the transition from Confidential to Confidential .
• Responsible for interpretation of Confidential ’s contract with the State of Michigan to determine critical gaps in corporate administrative and business management functions for operating a Medicaid Managed Care health plan.
• Drafted or revised corporate administrative and management policies and procedures to ensure compliance with state and federal regulations for Medicaid health plans
• Developed compliance and for all employees, providers and contractors
• Organized and submitted the Confidential annual audit of Confidential
• Responsible for direct reporting relationships with senior level management, area directors and principal attorneys, Managed Care Law
• Developed and implemented internal monitoring controls
• Developed and implemented a fraud, waste and abuse program for Confidential Advantage ( Confidential ) and Medicaid ( Confidential )

• Developed systems testing and materials for the Enterprise Provider Information Processing (EPIP) department
• Designed and developed work flows, business process documentation and integrated them with custom built information sets and data processing systems for all provider types